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The 



War Against Tuberculosis 

IN SAN FRANCISCO 



"It is within the power of man to cause all parasitic 
diseases to disappear from the world.". — Pasteur 




Published by 

San Francisco Tuberculosis Association 

SAN FRANCISCO, CALIFORNIA 
1928 




<*HPHE importance of the crusade against tubercu- 
losis cannot be overestimated. Science has dem- 
onstrated that this disease can be stamped out, but 
the rapidity and completeness with which this can 
be accomplished depend upon the promptness with 
which the new doctrines about tuberculosis can be 
inculcated into the minds of the people and engrafted 
upon our customs, habits, and laws. The modern 
crusade against tuberculosis brings hope and bright 
prospects of recovery to hundreds and thousands of 
victims of the disease, who under old teachings were 
abandoned to despair." — Theodore Roosevelt. 



San Francisco Tuberculosis Association 

Organized June 25, 1908, as The San Francisco Association for the Study 
and Prevention of Tuberculosis. 



OFFICERS 
John S. Drum, President 
George S. Hollis, Vice-President 
William H. Crocker, Treasurer 
Dr. William C. Voorsanger, Secretary 



DIRECTORS AND EXECUTIVE COUNCIL MEMBERS 



Dr. Mariana Bertola 
Dr. Philip King Brown 
Dr. W. R. P. Clark 
Mrs. William H. Crocker 
Rev. C. S. S. Dutton 
Mrs. Alice S. Ellinwood 
Mrs. Milton Esberg 
Dr. George H. Evans 
Dr. Harold K. Faber 
Alexander Fleisher 
Will J. French 
Dr. Morton R. Gibbons 



Archbishop Edward J. Hanna 
Franck R. Havenner 
Mrs. I. W. Hellman 
William F. Higby 
Dr. William J. Kerr 
Dr. Alson R. Kilgore 
Dr. William P. Lucas 
Mrs. Parker S. Maddux 
Dr. Sidney J. Shipman 
Mrs. Joseph Sloss 
Mrs. George B. Somers 



Office— -20 SECOND STREET 

Telephone Sutter 1534 
General Secretary, Paul Neiman 



FOREWORD 

"P OR more than twenty years it has been the constant endeavor of the 

San Francisco Tuberculosis Association to bring to bear against 

tuberculosis every influence that works toward reduction of the disease. 

Tuberculosis used to kill each year between 300 and 330 persons 
from every 100,000 living in San Francisco. Now it kills each year 
about 100 from every 100,000. 

Despite this great reduction tuberculosis still kills in San Francisco 
more persons in early adult life than are killed by any other disease. It 
still causes more suffering, more poverty and more dependency than any 
other disease. United public effort for its control and prevention must 
be continued and increased. It is true economy to provide public funds 
for hospitalization of those who have tuberculosis and lack the means 
to provide for themselves, and for such other public health activities as 
will accelerate the decline of this terrible and costly disease and eventu- 
ally wipe it out. 

Many thousands of persons have helped the Association in its work. 
Newspapers, public officials, churches, clubs, labor unions, lodges and 
other groups and individuals have aided the Association in such number, 
and so frequently, that it is impossible here to record their names but 
grateful acknowledgment is made to all. 

This booklet is published to review some of the things that have 
been done, to call attention to important changes that have taken place 
and to stimulate public interest in measures for further reduction of a 
preventable disease and the heavy economic loss that it causes. 



The Wide Extent and Great Cost of a 
Preventable Disease 



UEW persons realize how much tu- 
berculosis there is in large cities. 
Few realize how much it 
costs a city. In San Fran- 
cisco, as in nearly all cities, 
tuberculosis kills more per- 
sons in early adult life than 
any other disease. It is the 
greatest single cause of pov- 
erty and dependency. 

In San Francisco, of every 
ten beds provided by the tax- 
payers for the sick poor at 
the municipal hospital, four 
beds are for victims of tuber- 
culosis and six beds for the 
victims of all other ailments 
combined. The chart on this 
page shows how the days of 
free hospital care were di- 
vided in the fiscal year that 
ended June 30, 1928. 

Averaged, 875 beds were 
occupied by patients every day 



Days of free bed care provided for 
patients at San Francisco's munici- 
pal hospital in the twelve months 
ended June 30, 1928: 

1. TUBERCULOSIS 122,748 

2. General Medicine 60,129 

3. Surgery 50,878 

4. Isolation 20,162 

5. Children's Department .... 17,686 

6. Diseases of Women 13,421 

7. Genito-Urinary 12,023 

8. Maternity _ 6,885 

9. Eye, Ear, Nose, Throat.. 5,376 

10. Venereal 5,333 

11. Nervous and Mental 4,727 

Total 319,368 




of the year. Of these, 336 were oc- 
cupied by tuberculosis patients and 
539 by all other patients. 

Despite the large proportion of 
beds provided for tuberculosis pa- 
tients there is almost continuously a 
waiting list, as there is for nearly all 
departments of the hospital because 
of the recent great growth of San 
Francisco. At times recently as many 
as 290 tuberculosis patients have been 
cared for in hospital space built for 
250. 

The long time that must pass be- 
fore tuberculosis is cured, or before it 
kills, is one reason why such a large 
part of the free bed care provided at 
public expense is required for the vic- 
tims of this one disease. 

The foregoing figures have to do 
only with bed care inside hospital 
walls. Throughout the year more 
than 2000 persons with tuberculosis, 
or believed in danger of getting it, 
were under free medical and nursing 
supervision at clinics and in their 
own homes. More 
than half were 
children less than 
16 years old. 

Tuberculosis, al- 
though a prevent- 
able and curable 
disease, and al- 
though it has been 
greatly reduced, 
still kills about 600 
persons in San 
Francisco every 
year. This toll is 
taken principally 
from among per- 
sons between 20 
and 50 years of 
age. 



Ibisbi 



The chart illustrates the distribution 
of deaths by 10-year age groups. It 
is drawn from the average of the last 
five years. The variation in any one 
year from any of the group averages 
is not great, for tuberculosis is a re- 
markably steady and consistent killer. 

AVERAGE NUMBER OF TUBERCULOSIS 
DEATHS PER YEAR IN SAN FRANCISCO FOR THE 
LAST FIVE YEARS, BY 10-YEAR AGE GROUPS- 




"der in 20 



30 40 

to to 

39 49 



50 60 o»er 



59 



70 



Note on the chart that tuberculosis 
kills most of its victims in their twen- 
ties. Note that it kills not the aged, 
who have lived out man's allotted 
span of years, but those on the thresh- 
old and in the prime of life. Tuber- 
culosis, like war, kills off the young 
men. It kills twice as many men as 
women in San Francisco. 

A few other diseases kill a greater 
number of persons, but they kill prin- 
cipally among the aged. In San Fran- 
cisco, diseases of the heart kill about 
twice as many persons as tuberculosis, 
but those killed by heart diseases are 
nearly all well along in years. Almost 
half are past 70 years of age. 

Tuberculosis causes a vast amount 
of poverty and dependency not only 
because it kills great numbers of young 
men who leave children not yet old 
enough to be self-supporting, but also 
because it is a long-drawn-out disease, 
causing complete disability of the 



wage-earners in many families for 
months and years at a time. 

"Approximately 33 per cent of all 
relief work is for families in which 
tuberculosis is the main if not the only 
cause of dependency. Forty-one per 
cent of the relief for widows given by 
the city is in families where tubercu- 
losis caused the husband's death. Of 
the money spent for child welfare, in 
42 per cent it was the death of the 
father from tuberculosis that caused 
the dependency of the children. About 
one-half of the entire cost of the relief 
work of the city's principal charity 
agency is due to needs, in families and 
among individuals, created by tuber- 
culosis/' 

The foregoing quotation relates to 
New York City. Comparable per- 
centages for San Francisco are not 
available but would doubtless equal or 
exceed those of New York, for San 
Francisco's death rate from tubercu- 
losis has always been much higher 
than New York's. 

Medical authorities estimate that 
for each death yearly from tubercu- 
losis in a community there are seven 
living persons with the disease in such 
condition that medical and nursing 
supervision and care are needed. If 
this estimate is correct, there are in 
San Francisco all the time more than 
4,000 persons seriously sick with tu- 
berculosis. 

Medical authorities also estimate 
that tuberculosis lasts, on an average, 
five years. Ordinarily among the cases 
that end fatally death is preceded by a 
long period of complete disability. 
This is estimated by some authorities 
to average 2]/z years, and by others 
3 years. Complete cure, also, must 
generally be preceded by months and 
years of inactivity. 

It is not so difficult to cure tubercu- 
losis if the disease is discovered near 
the time of its beginning and sanator- 
ium care is provided, or home care 
under competent medical and nursing 
supervision. Unfortunately the dis- 
ease is too seldom discovered early, 



and too often it is impossible to pro- 
vide sanatorium care or to arrange 
home conditions suitable for cure. 

Tuberculosis is unlike many dan- 
gerous communicable diseases. It does 
not suddenly make violent attack on a 
community and then subside into a 
long period of inactivity. It kills at 
a comparatively even rate all the time, 
year after year, month after month. 

Persons do not generally realize the 
full extent of tuberculosis, the great 
loss it causes, and the need for large 
public expenditures to combat it, be- 
cause it is not a sudden or spectacular 
killer. It does not flare up in out- 
breaks like bubonic plague, or small- 
pox, or typhoid, or influenza, that 
arouse public alarm and public de- 
mand for prompt defensive measures. 
And yet tuberculosis kills many more 
than are killed by these other four 
plagues combined. 

In 1907 bubonic plague broke out 
in San Francisco. Private citizens, 
city, state and federal officials promptly 
combined to fight it. Laws to aid in 
control and prevention of the plague 
were passed. Public funds were ap- 
propriated liberally. By popular sub- 
scriptions $152,000 was added to the 
appropriations. Within a few months, 
by an expenditure of $585,000, the 
plague was checked. 

In 1907 the plague killed only 89 
persons in the whole United States, 
and it has never since killed more than 
30 in any one year in the United 
States. A Census Bureau report says : 

"Those 89 deaths in 1907 probably 
occasioned greater alarm than would 
be felt if tuberculosis caused 10,000 
more deaths than usual." 

As the result of that public alarm, 



prompt and far-reaching action was 
taken. Thanks to the continued vigi- 
lance of federal, state and local health 
officials the plague has killed only a 
few more than 100 persons in the 
whole United States in the last 20 
years. In the same 20 years tubercu- 
losis, although gradually declining, has 
killed more than 2,000,000 persons, 
more than 100,000 per year. 

Since 1908 only three persons have 
died of plague in San Francisco. Yet 
tuberculosis, "the white plague," 
which also to a large extent could be 
controlled and prevented, has killed 
more than 15,000 persons in San 
Francisco in that time. 

That last outbreak of bubonic 
plague in San Francisco in 1907 and 
1908 killed 77 persons. In the same 
years the white plague killed more 
than 800 persons each year, but no 
one was sufficiently alarmed to do 
anything about it except a small group 
of persons who were organizing "an 
association for the study and preven- 
tion of tuberculosis" and preparing to 
open San Francisco's first tuberculosis 
clinic for the sick poor. 

When one considers, then, the large 
number of persons who have tubercu- 
losis, the difficulty of early discovery, 
the long time required to overcome 
the disease once it has gained a strong 
foothold, as it usually has before it is 
discovered, and that its victims are 
principally persons in early adult life, 
it is easier to understand why tuber- 
culosis is by far the most costly of all 
diseases to a community and why 
large expenditures of public money 
must be made to control and pre- 
vent it. 



TUBERCULOSIS DEATHS IN SAN FRANCISCO DIVIDED INTO 10- YEAR 



Ages Under 10 10-19 

1923 54 36 

1924 38 37 

1925 38 39 

1926 39 44 

1927 45 31 

Annual 

Average 42 37 



AGE GROUPS 

20-29 30-39 40-49 50-59 60-69 Over 70 Total 



132 
148 
126 
145 
146 

139 



128 
126 
124 
126 
109 

122 



148 
151 
140 
103 
107 

129 



89 
84 
82 
86 
84 

8 5 



67 
51 

70 
51 
58 

59 



13 
26 

25 
17 
13 

18 



667 
661 
644 
611 
593 

635 



History of the Early Efforts to Check 
Tuberculosis in San Francisco 



FOR years prior to 1906 San Fran- 
*"■ cisco had the highest tuberculosis 
death rate, by far, of America's ten 
largest cities, but no attempt was made 
to do anything about it. There was 
widespread and deeply rooted belief 
that "consumption" was a calamity 
about which nothing could be done, 
and that the less said about it the 
better. 

Early in 1906 the first steps were 
taken toward control and prevention 
of the disease. A few physicians and 
other persons who believed something 
might be done toward reducing the 
loss of nearly 100 persons in early 
adult life every month, year after year, 
and who believed that public action 
should be taken toward ameliorating 
the hard lot of the many persons dis- 
abled and impoverished by the dis- 
ease, laid plans to organize the San 
Francisco Association for the Study 
and Prevention of Tuberculosis. 

They decided to start a campaign 
of "prevention through education," to 
open a free tuberculosis clinic for the 
sick poor, to send visiting nurses to 
those sick at home, and to urge public 
officials to make better provision for 
hospitalization of tuberculosis cases. 

As a beginning, $2,550 of munici- 
pal funds was provided to erect and 
equip tents with board floors in which 
to try the open air treatment on a 
score of the city's dependent tubercu- 
losis cases. A newspaper account pub- 
lished early in April, 1 906, said : 

"The first open air treatment for 
consumptives at a public institution 
west of Denver will begin shortly at 
the city and county hospital under the 
direction of Dr. George H. Evans. 
The first tent was erected yesterday 
and when the remaining nine are com- 
pleted twenty patients will be accom- 
modated. The work is in the nature 



of an experiment, but great results are 
expected." 

This tent colony, on the grounds of 
the municipal hospital, was fenced 
with wire. The fence represented the 
first exercise of public authority in 
San Francisco for segregation of per- 
sons dangerously sick with tuberculo- 
sis from others that might catch the 
disease from them. 

Up to that time no attempt to pre- 
vent the spread of the disease had 
been made, although it had been 
known for years that it is communi- 
cable. There was no law to require 
reporting of tuberculosis and no ma- 
chinery for its control existed. Far 
advanced cases were mingled indis- 
criminately among patients brought to 
the hospital with other ailments. A 
dying consumptive might be sharing 
his quarters and his eating utensils 
with patients recovering from other 
respiratory diseases and thus passing 
on his disease to those with weakened 
resistance. 

Possibly this state of affairs had 
something to do with the fact that up 
to 1906 San Francisco had by far the 
highest tuberculosis death rate of 
America's ten largest cities. 

Plans for the campaign against tu- 
berculosis were completed early in 
April, 1906. The evening of April 18 
was selected for a public meeting at 
which officers would be chosen and the 
work formally started. The meeting 
was not held, for on April 18 came 
earthquake and fire. 

In the days that followed, the or- 
ganizers of the Association had many 
other tasks and responsibilities that 
postponed their planned activities 
against tuberculosis. Bubonic plague 
broke out in the fall of 1907 and many 
of them served on the Citizens' Health 
Committee that raised $152,000 by 
private subscriptions and worked with 
public officials against that disease. 



Early in 1908 plans for a campaign 
against tuberculosis were taken up 
again. 

Organization began at a luncheon 
meeting over which Mrs. William H. 
Crocker presided. Other meetings 
were held at luncheons down town 
and on a number of evenings at the 
home of Mrs. John F. Merrill. 

On June 25, 1908, organization 
of the Association was completed. 

The first officers and directors, 
chosen at this meeting, were : 

Thomas E. Hayden, President 
Dr. Herbert C. Moffitt, First Vice-President 
Mrs. John F. Merrill, Second Vice-President 
Dr. Rene Bine, Treasurer 
Dr. William C. Voorsanger, Secretary 
DIRECTORS 

J. J. Bakewell, Jr. 

Mrs. E. L. Baldwin 

Henry U. Brandenstein 

Gustave Brenner 

Dr. Rene Bine 

Dr. Charles M. Cooper 

Mrs. William H. Crocker 

Mrs. S. W. Dennis 

Dr. George H. Evans 

Miss Katherine Felton 

Thomas E. Hayden 

Dr. A. W. Hewlett 

Walter Macarthur 

Miss Laura McKinstry 

Mrs. John F. Merrill 

Dr. Herbert C. Moffitt 

Charles C. Moore 

Mrs. S. S. Palmer 

Mrs. Henry Payot 

Osgood Putnam 

A. W. Scott, Jr. 

Dr. Harry M. Sherman 

Mrs. M. C. Sloss 

Dr. William C. Voorsanger 

Thomas E. Hayden served as pres- 
ident of the Association from its or- 
ganization until January, 1912. He 
was succeeded by Jesse W. Lilienthal, 
who continued as president until his 
death in June, 1919. Since October, 
1919, John S. Drum has been the As- 
sociation's president. Dr. William C. 
Voorsanger has been the Association's 
secretary ever since its organization. 

The Association was incorporated 
in 1911. In 1920 its name was short- 
ened, for convenience, from "The San 
Francisco Association for the Study 
and Prevention of Tuberculosis" to 
"San Francisco Tuberculosis Associa- 
tion." 

The Association launched its 
educational campaign with this dec- 
laration to a skeptical world : "Tuber- 
culosis is a preventable and usually a 
curable disease." 



It announced that it purposed "to 
teach all who will learn, how not to 
get the disease, how not to give the 
disease and how to get well of it," 

To this end a free clinic was 
opened, visiting nurses were sent from 
house to house, lectures were given, 
sermons were preached, handbills were 
circulated, advertisements were posted 
in street cars, articles were published 
in newspapers, exhibits of good and 
bad housing as related to disease were 
displayed and every means at the com- 
mand of the Association was used to 
create an informed public opinion. 
Ever since its beginning it has been 
the aim of the Association to bring to 
bear against tuberculosis every possi- 
ble influence that may aid toward its 
final conquest. 

Aside from its general educational 
activities the Association undertook to 
bring about state and county legisla- 
tion that would give boards of health 
the legal power and necessary finan- 
cial appropriations to provide better 
care for the indigent sick and to take 
measures for control and prevention 
of the disease. 

In its first year the Association, 
through its committee on legislation, 
of which Walter Macarthur was 
chairman, succeeded in getting such 
legislation through the Senate and 
Assembly, but it was vetoed by the 
Governor. In 1909 the Association 
was successful in having adopted in 
San Francisco an ordinance in which 
tuberculosis was officially declared "a 
communicable disease dangerous to 
the public health" and the local board ■ 
of health was empowered to take cer- 
tain steps to prevent the spread of 
infection. 

From its beginning the Association 
was active in support of building laws 
that would insure proper space for 
sunlight and fresh air in the recon- 
struction of the city. A remarkable 
decrease in San Francisco's death rate 
from tuberculosis followed the purg- 
ing of the city by fire. Many sunless 



and ill-ventilated old habitations were 
burned. In the rush of reconstruc- 
tion many dwellings were erected that 
would not be permitted under the 
building laws of today, but in general 
the new buildings were far superior 
from a health standpoint to those that 
they replaced. A tenement house or- 
dinance that was passed in June, 1907, 
principally through the efforts of the 
Telegraph Hill Neighborhood Asso- 
ciation, was in a large measure re- 
sponsible for this. 

To local efforts for better housing, 
and for inspection of milk, meat and 
other foodstuffs, all of which have a 
bearing on the prevention and control 
of tuberculosis, the Association gave 
its support. Meanwhile it continued 
its efforts to have similar action taken 
by the state. The annual report of 
the Association for 1911 says: 

"In February, March and April 
of 1911 several trips were made to 
Sacramento by President Thomas 
Hay den, Dr. William C. Voor Sanger, 
Dr. R. G. Brodrick and Chairman 
Macarthur of the legislative commit- 
tee in the interest of Assembly Bill 
821, authorizing the state board of 
health to make a special investigation 
into the prevalence of tuberculosis, 
and of Senate Bill 292, requiring the 
registration of all cases of tuberculosis, 
which bills were introduced into the 
last legislature by this Association/' 

The work of the Association's com- 
mittee on legislation eventually led to 
the shaping of state policies by which 
many excellent county tuberculosis 
hospitals have been established in Cali- 
fornia and maintained at high stand- 
ard under state supervision and with 
the aid of a state subsidy. 

The state board of health, under 
authority given by one of the bills 
sponsored by the Association in 1911, 
appointed a tuberculosis commission 
of five and an advisory committee of 
fifty to investigate the prevalence of 
tuberculosis in California and to rec- 
ommend ways and means for its con- 
trol and prevention. 



Dr. George H. Kress, Los Angeles, 
was chairman of the commission. Dr. 
R. G. Brodrick and Miss Katherine 
C. Felton were San Francisco mem- 
bers of the commission. Sixteen other 
San Franciscans served on the advis- 
ory committee. They were : 

Rev. Charles F. Aked 
J. J. Bakewell, Jr. 
Charles H. Bentley 
Dr. Philip King Brown 
Rev. D. O. Crowley 
Miss Margaret B. Curry 
Frederick W. Dohrmann 
Dr. George H. Evans 
Miss Alice Griffith 
Mrs. M. W. Kincaid 
Walter Macarthur 
Rabbi Martin A. Meyer 
John I. Nolan 
Dr. William Ophuls 
Dr. William C. Voorsanger 
Frederick S. Withington 

A thorough study of the tuberculo- 
sis situation in California was made 
and a report submitted to the legisla- 
ture. As a result a state bureau of 
tuberculosis was created to cope with 
the disease, legislation enabling coun- 
ties to combine for the purpose of 
erecting tuberculosis hospitals was en- 
acted, state subsidy was provided for 
county tuberculosis hospitals that 
could comply with . certain specified 
standards of care and treatment, and 
much other legislative action calcu- 
lated to control and prevent the dis- 
ease followed in the next few years. 

The recommendations of the state 
tuberculosis commission of 1911 in- 
cluded many things besides free bed 
care in hospitals and country sanatoria 
for persons with tuberculosis unable 
to provide hospital care for them- 
selves, and free dispensary care for 
those not in need of hospitalization. 
The commission also recommended 
governmental inspection of milk, meat 
and foodstuffs ; stricter housing laws ; 
inspection of tenements, factories and 
lodging houses; regulated hours of 
labor; public playgrounds and recrea- 
tion centers; medical inspection of all 
school children and the teaching of 
health as a regular part of school 
work. 

Great advances along all these lines 
have been made since that time and 
all, no doubt, have played a part in 



10 



the reduction of the tuberculosis death 
rate that has taken place. 

Throughout its earlier years finan- 
cial support for the Association was 
principally supplied by a compara- 
tively few persons. The continuous 
employment of field nurses and main- 
tenance of clinics was made possible 
only by large gifts from Mrs. William 
H. Crocker. San Francisco business 
firms provided without charge much 
of the material for constructing and 
equipping the building on Jackson 
Street that for many years housed the 
association's offices and free clinics. 

Donations that the Association re- 
ceived were supplemented by the sale 
of Christmas seals. Mrs. John F. 
Merrill, one of the organizers of the 
Association, and also Mrs. Henry 
Payot, were principally responsible 
through their management of the sale 
for developing it into the Association's 
principal source of funds. Mrs. Wil- 
liam Haas was another who not only 
took an active part in the Association's 
work, but also made large contribu- 
tions for its financial support. 

The annual sale of penny seals at 
Christmas time now supplies the ma- 
jor part of the Association's funds. 
The seal sale is one of the Associa- 
tion's most effective ways of stimulat- 



ing public interest in the tuberculosis 
problem. It has also proved to be 
each year directly responsible for the 
discovery by the Association of addi- 
tional cases of tuberculosis, not pre- 
viously known to physicians or field 
nurses. 

In earlier years the seals were sold 
upon the streets and at public gather- 
ings by volunteer solicitors. Later the 
custom of offering the seals by mail 
was adopted and the sale now is al- 
most entirely by mail. 

The funds of the Association are 
carefully used under direction of an 
executive council. Until 1928 it met 
twice each month. It now meets once 
a month. The books of the Associa- 
tion are audited each year. 

The Association maintains an of- 
fice at 20 Second Street that is open 
every day except Sunday. Books, mag- 
azines, pamphlets, posters, lantern 
slides and motion picture films having 
to do with tuberculosis, and other 
health topics, are kept on hand. Some 
of this material is given away and any 
of it may be borrowed. Information 
about tuberculosis, about the work of 
the Association, and the ways in which 
its funds are spent will be freely given 
to anyone. 




ASSOCIATION HEADQUARTERS 1909-1921 
11 



Some of the Things That Hare Been Done 
To Control and Prevent Disease 



HP HE first tuberculosis clinic was 
^ opened by the Association in Jan- 
uary, 1909. The Telegraph Hill 
Neighborhood Association provided 
clinic rooms. Dr. William C. Voor- 
sanger, Dr. W. R. P. Clark and Dr. 
James L. Whitney did the medical 
examining. A few months later the 
Association completed a building at 
1547 Jackson Street for its headquar- 
ters. Here the major part of the 
clinic work was carried on until July, 
1921, when it was taken under mu- 
nicipal administration. 

More than 24,000 men, women 
and children have been enrolled as 
new patients in the twenty years the 
tuberculosis clinics have been in op- 
eration. In the first six years from 
350 to 450 new patients were enrolled 
each year. In the last six years from 
1500 to 2000 new patients have been 
enrolled annually. 

When the Association established 
its first free clinic twenty years ago it 
met open hostility. Citizens demanded 
that the clinic be closed by the Board 
of Supervisors, threats were made to 
close it by injunction, protests even 
were made against display of the 
word "tuberculosis" at the clinic en- 
trance. In time the purpose of the 
clinic, and the value of its work, be- 
came better understood and public 
feeling about it changed. 

The number of visits to the clinic 
made by patients in the first year was 
about 1600. Attendance has grown 
until about 6800 visits are now made 
to the clinics by patients each year for 
examination and advice. 

The accompanying chart shows 
how clinic attendance has increased. 
A greater increase in recent years 
would be shown were it not for the 
fact that the Association has main- 
tained for the last three years two 
special clinics at Stanford and Uni- 
versity of California hospitals in San 



Francisco for a study of tuberculosis 
in children. Many children have at- 
tended these clinics who would other- 
wise have attended the older clinics 
for persons of all ages. Attendance 
at these two special clinics is not in- 
cluded in the totals from which the 
chart was drawn. 

In addition to the work done in 
clinics the Association has provided 
tuberculosis examinations for many 
thousands more in places where men 
and women work, in public and pri- 
vate schools and in clubs and com- 
munity centers. In the last year phy- 
sicians provided by the Association 
have examined more than 12,000 per- 
sons in such places. 

A field nursing force to seek out 
new cases and supervise the home care 
of tuberculosis patients for whom hos- 
pital provision could not be made was 
built up by the Association as rapidly 
as its finances permitted. Efforts to 
convince the city that tuberculosis is 
a municipal problem were continued. 
The president of the Association 
stated in 1911 : 

"Much of the work we are doing 
now ought to be done by the city. 
One purpose of organizing this society 
was to lay the foundation for work 
to go on under city administration." 

In 1916 three nurses were supplied 
through municipal funds to carry on 
tuberculosis field work in connection 
with the five nurses paid by the Asso- 
ciation. The city was divided into 
eight districts and a nurse assigned to 
each. 

The annual report of the municipal 
Board of Health for 1917 says: 

"For the first time in its history, 
the city of San Francisco took upon 
itself the responsibility of grappling 
with the problem of handling the tu- 
berculosis situation, the board of su- 
pervisors in the budget of 1916-17 



12 



having set aside $5,000 for the estab- 
lishment of a bureau of tuberculosis." 

On July 1, 1921, appropriations 
for the municipal bureau of tubercu- 
losis were increased so it could take 
over the clinic and field nursing work. 
The Association still supplements this 
work in various ways. At present the 
municipal bureau of tuberculosis pro- 
vides ten visiting nurses and the Tu- 
berculosis Association four. The As- 
sociation also helps the field nurses 
keep in touch with patients discharged 
from the hospital by supplying a part- 
time clerical assistant. 

It is not the Association's true func- 
tion to carry on medical and nursing 
work that properly should be done by 
the municipal department of public 
health, except temporarily such work 
as cannot be undertaken by the de- 
partment for lack of funds. The As- 
sociation's medical and nursing enter- 
prises are arranged to supplement 
those of the department and are car- 



ried on under municipal direction and 
control. Duplication of effort and 
expense is avoided. 

Health work among school children 
began in a small way in San Fran- 
cisco in 1908 when the board of su- 
pervisors gave the health department 
funds to start one medical inspector 
and four nurses. From time to time 
the school inspection staff has been 
increased. It is not yet of sufficient 
size to meet adequately the needs of 
a city in whose public and private 
schools and kindergartens approxi- 
mately 100,000 children assemble 
each school day. 

In February, 1916, the Association 
joined with the board of education 
in establishing an open-air school to 
provide for children in poor physical 
condition the close supervision and 
special care necessary to restore them 
to vigorous health without interrupt- 
ing their attendance at school. The 
board of education provided housing 




ATTENDANCE AT FREE TUBERCULOSIS 
CLINICS IN SAN FRANCISCO SINCE THE FIRST 
CLINIC WAS OPENED BY THE TUBERCULOSIS 
ASSOCIATION IN JANUARY 1909 *<*»- 



HALF 
YEAR 
JAN1 

to 
JUNE 

30 



7000 
6500 
6000 
5500 
5000 
4500 
4000 
3500 
3000 
2500 
2000 
1500 
IOOO 

500 

O 



1909 »0 II 12 13 14 IS 16 17 18 19 20 21 21-22 22 23 2W* 2425 2526 2M7 2728 
CALENDAR YEARS " FISCAL YEARS ' 



13 



accommodations and teachers. The 
Association provided medical and 
nursing care, meals, cots, blankets and 
similar equipment. 

A second open-air school was opened 
in May, 1919. Two years later ap- 
propriations for the municipal bureau 
of tuberculosis were sufficiently en- 
larged to permit it to undertake, with 
the board of education, complete su- 
pervision and support of open-air 
schools. 

In 1921 the Association helped the 
municipal departments of health and 
education establish health teaching 
and health supervision classes in San 
Francisco's elementary public schools. 
As a beginning, 44,500 children in 93 
schools were weighed, measured and 
given preliminary physical examina- 
tions. 

With the co-operation of parents 
and family physicians, and through 
free treatments at clinics for those 
from families financially unable to 
provide their own medical care, hun- 
dreds of children have been freed 
from physical handicaps that tend to 
undermine health and retard prog- 
ress in school. 

Arrangements were made to teach 
healthful habits of living in all the 
schools and to provide inexpensive and 
nutritious luncheons at cost. Health 
supervision classes were formed for 
the benefit of children in need of spe- 
cial attention and instruction to bring 
them to robust health without inter- 
ruption of school attendance. 

The Association provided a number 
of teachers, doctors and nurses to help 
carry this additional work through 
the experimental period. From time 
to time the regular employes of the 
departments of health and education 
took over parts of this work and by 
July, 1925, all of it. 

Meanwhile the health department 
and the directing heads of San Fran- 
cisco's parochial educational system 
started similar health work in the 
parochial schools, which the Associa- 
tion is aiding them to extend. 

The value of school health work is 



not so much in the discovery of stu- 
dents with active tuberculosis as in the 
discovery of physical impairments and 
weaknesses of various kinds that, if 
permitted to continue, lay a child open 
to successful attack by tuberculosis in 
the critical years of early adult life. 
Tuberculosis kills in San Francisco 
fewer persons between the ages of 10 
and 20 than it kills in any other 10- 
year age group. But from those in 
their twenties it takes its heaviest toll, 
and particularly in the early twenties. 

The Association believes that an- 
nual medical inspection of all school 
children, and particularly of those in 
the high schools and part-time schools, 
combined with corrective work, will 
serve to arm with natural resistance 
sufficient to carry them safely through 
adult life, many boys and girls who 
would otherwise be overcome by tu- 
berculosis in their twenties. 

It has therefore supplemented the 
limited resources of the school medical 
inspection service by supplying doc- 
tors and nurses, who work under the 
direction of the city health officer as 
members of his school staff. Doctors 
employed by the Association examined 
more than 10,000 high school and 
junior high school students last year. 
Assistance from the State Bureau of 
Tuberculosis and the California Tu- 
berculosis Association made it possible 
to increase the effectiveness of inspec- 
tion by use of an x-ray laboratory 
mounted on a motor truck. X-ray 
examinations were made of the chests 
of more than 3,000 students. 

Search for a quick cure for tuber- 
culosis goes on continuously in hospi- 
tals and laboratories throughout the 
world, still unsuccessfully. Develop- 
ment of the x-ray as an aid to early 
discovery of tuberculosis, and im- 
provements in chest surgery as a 
means of arresting the disease in cer- 
tain cases, are advances in medical 
science, but there is not yet any quick 
cure, any sure cure, any cheap cure 
for tuberculosis. Rest, good food, sun- 
shine, fresh air, a carefully ordered 
method of life, and patience are re- 



14 



quired to win back health, once it is 
lost. 

The Association has helped to a 
small extent, when money was avail- 
able for the purpose, in the search for 
a cure that will be quicker, surer and 
less expensive than the long course of 
sanatorium treatment now required. 

In 1921 it helped finance at the 
University of California hospital re- 
search work by which it was then be- 
lieved a cure for tuberculosis might 
be developed from chaulmoogra oil. 
Careful and thorough experiments 
proved that this belief was incorrect. 

At present certain studies with tu- 
berculin are being carried on in the 
research department of the University 
of California hospital. Toward the 
expense of this work the Association 
contributed $500. 

Next to prevention, which is always 
better and cheaper than cure, early 
discovery is the most important objec- 
tive of the campaign against tubercu- 
losis. Medical authorities say that 
tuberculosis lasts, on an average, five 
years. The nearer to the time of be- 
ginning that the disease is discovered 
the less difficult it is to check it. It 
is known that most persons are first 



infected with tuberculosis in childhood. 

To study this childhood infection, 
to determine the frequency with which 
it occurs in San Francisco among 
children of various ages, and to de- 
velop more exact methods of discover- 
ing and controlling the infection, two 
free clinics for children from infancy 
to fifteen years of age have been main- 
tained by the Association at Univer- 
sity of California and Stanford hospi- 
tals for the last three years. 

Approximately 4,000 children have 
been enrolled at these clinics. Many 
were found with tuberculosis and sent 
to hospitals. Others suspected of hav- 
ing the disease, or believed likely to 
get it because of poor physical condi- 
tion, have been re-examined from time 
to time and provided with home nurs- 
ing supervision. Many have been sent 
to convalescent homes and similar in- 
stitutions. 

More than 3,000 x-ray pictures 
have been taken. From these, and 
from carefully recorded observations 
of physicians and nurses employed by 
the Association, much has been learned 
to make possible the earlier discovery 
and more effective treatment of tuber- 
culosis in children. 



i 

r * 


IT 


y mi' 



SCHOOL MEDICAL INSPECTION WITH STETHOSCOPE AND X-RAY 

15 



More and Better Hospital Care Provided 
for Victims of the White Plague 



HP O obtain adequate public care for 
^ those with tuberculosis unable to 
provide for themselves has always 
been one of the aims of the Associa- 
tion. Progress in this was particu- 
larly difficult in early days. The num- 
ber in need of hospitalization was so 
great that public officials contended 
no municipality could raise sufficient 
money to meet the problem. Public 
knowledge of and interest in health 
work had not been developed. Munic- 
ipal appropriations for public health 
protection were small. 

In San Francisco, public officials, 
harassed by financial difficulties and 
pressing needs in reconstruction of the 
city after the disaster of 1906, paid 
scant attention to the plight of the 
tuberculous. Their attitude was re- 
flected in quotations from health de- 
partment reports of that time: 

"There seems to be no means of 
lessening the number of those suffer- 
ing from this dread disease. It seems 
as though the federal government 
should care for this class of patients as 
their disease is lasting and communi- 
cable and no municipality should be 
expected to bear the expense." 

The same reports contain the in- 
formation that "an anti-tuberculosis 
league is trying to combat the inroads 
of this dread disease." 

The City and County Hospital, a 
dilapidated frame structure 35 years 
old, escaped the great fire of 1906, 
but at the finish of the campaign 
against bubonic plague, whose victims 
it had sheltered, it was torn down and 
the wreckage was burned. Patients 
had been moved to a temporary hospi- 
tal in an old building at the county 
poor farm in January of 1908. 

Two months later that building 
was destroyed by fire. Arrangements 
were made to scatter the sick poor 
among private hospitals, the govern- 
ment hospital at the Presidio and 
barns at the Ingleside race track. The 



Associated Charities fitted up one of 
the barns for a tuberculosis hospital. 
The municipal appropriation for 
maintenance amounted to 74 cents per 
patient per day. Appropriations of 
other cities at that time were double 
that amount. 




TUBERCULOSIS HOSPITAL 1908-1911 

The board of health, calling atten- 
tion in its annual report for 1908 to 
the need for better quarters for the 
sick, had this to say of the hospital : 

"Although everything was done to 
put the buildings, which formerly 
were used as stables for race horses, 
in a habitable condition, naturally the 
result is not all that could be desired. 
All the buildings are old and the roofs 
more or less leaky, which will cause 
much annoyance in the approaching 
rainy season. Some of the buildings 
are open to such an extent that it will 
be practically impossible to heat them; 
others again do not provide for suf- 
ficient ventilation." 

Many entries similar to the follow- 
ing appear in the old minute books of 
the Tuberculosis Association : 

"Mrs. Henry Payot, Mr. Jesse W. 
Lilienthal and Dr. R. G. Brodrick 
were appointed to appear before the 
board of supervisors and request that 
the appropriation for maintenance of 
tuberculosis patients be increased." 

"Dr. A. H. Giannini and Dr. 
William C. Voor Sanger were directed 
to go to Sacramento and urge upon 
the legislature passage of a bill pro- 
viding for a state subsidy to county 
tuberculosis hospitals" 



16 



From time to time municipal appro- 
priations for maintenance of tubercu- 
losis patients were increased. San 
Francisco now spends more than 
$3.00 per patient per day. Part of 
this is provided by state subsidy, which 
began in July, 1916. The annual re- 
port of the health department at that 
time says: 

"Commencing July 1, 1916, the 
State subsidized 85 beds in the tuber- 
culosis hospital at the rate of $3 per 
week per patient, in consideration of 
the hospital's complying with certain 
housing and food regulations. By rea- 
son of the improvements made, the 
number of subsidized beds was in- 
creased from 85 to 100, effective 
March 1, 1917. The total subsidy 
for the year amounted to $13,368." 

Since the beginning of state subsidy 
a total of approximately $300,000 has 
been received from this source for 
maintenance of patients in San Fran- 
cisco's tuberculosis hospital. 

In May, 1911, the Association 
launched a public protest against the 
miserable conditions under which tu- 
berculosis patients were compelled to 
exist in the horse barn hospital. Other 
agencies joined with it. In July the 
Association committee directing the 
campaign reported : 

"After considerable work a munic- 
ipal appropriation of $30,000 has 
been authorized for construction of a 
lean-to tuberculosis department on 
San Francisco hospital grounds at 
Vermont and Twenty-second Streets, 
same to be completed in 60 days" 



Seven temporary wooden struc- 
tures were erected to provide for 150 
patients. They were first occupied 
in the fall of 1911 and continued to 
serve as the city's tuberculosis hospi- 
tal until July, 1919. The present 
hospital was then completed and op- 
ened for patients. Although built to 
house 250 patients, it has provided 
beds for as many as 290 adults at one 
time. In April, 1927, an addition 
that houses sixty children was com- 
pleted. In September, 1927, the 
Health Farm, a hospital in the coun- 
try near Redwood City for early cases 
of tuberculosis, was opened. It houses 
40 patients. 

Construction of the Health Farm 
hospital was preceded by a long search 
for the most suitable site in the coun- 
try near San Francisco. The Health 
Farm, a partly wooded tract of a lit- 
tle more than 300 acres, is situated 
on a sunny slope about 25 miles from 
San Francisco at an elevation of 600 
feet. It overlooks the southern arm 
of San Francisco Bay and is sheltered 
by a range of hills that holds back the 
cold wind and fog from the Pacific 
Ocean. The Health Farm has about 
100 more days of sunshine in a year 
than are enjoyed by San Francisco. 

Here exist ideal conditions for res- 
toration to health and economic use- 
fulness of many young persons in San 
Francisco with tuberculosis in its early 
stages. Lacking suitable care, such 
cases drift along into the advanced 
stages of the disease and in the end 
impose a greater economic burden on 




TUBERCULOSIS HOSPITAL 1911-1919 
17 



the community than if sufficient funds 
were provided to give them promptly 
institutional care at the time when 
there is the best opportunity to check 
their disease. 

To establish the Health Farm it 
was necessary to amend the charter of 
the City and County of San Fran- 
cisco. The amendment was submitted 
to the voters in the fall of 1922. It 
received 88,000 favorable votes and 
carried by a ratio of A 1 /, votes to 1, 
the greatest vote of approval given to 
any of the 53 measures that were on 
the ballot at that election. 

It is now planned to double the 
bed capacity of the Health Farm, 
bringing it from 40 to 80 beds, as well 
as to enlarge the main tuberculosis 
hospital in San Francisco, with funds 
from a bond issue for health purposes 
that is to be submitted to the voters in 
November, 1928. If this plan is ap- 
proved by the voters, it will make pos- 
sible the restoration to health of many 
sufferers from tuberculosis for whom 
it is not now possible to provide 
proper care. 

A vast improvement in tuberculosis 
hospitals has taken place throughout 
California since united efforts to con- 
trol and prevent the disease were 
started and public interest in the tu- 
berculosis problem was aroused. The 
situation that existed until a few years 
ago is pictured by this quotation from 
the state tuberculosis commission's 
final report to the legislature, pub- 
lished in 1914: 



"It is doubtful if the county hospi- 
tals, with a few exceptions, are at this 
time properly conducted as regards 
the treatment of tuberculosis. Most 
of them simply provide a place for 
advanced cases to die. Some of the 
counties have wards and separate 
buildings, specially designed for the 
treatment of tuberculosis, but in the 
majority of these places there are ab- 
solutely no facilities either for treat- 
ing the patients or for protecting those 
suffering from other diseases. County 
sanatoria and hospitals where residents 
sick with tuberculosis might really 
have a fair opportunity for restoration 
of health and usefulness are still in 
the incipient stage" 

Of San Francisco's municipal tu- 
berculosis hospital the report to the 
legislature said: 

"In this hospital now most of the 
patients received are in an advanced 
stage, and it is too late to do very 
much for them except to provide sim- 
ple comforts until such time as they 
shall die" 

Happily these conditions have been 
greatly changed. Since 1919 San 
Francisco has had a municipal tuber- 
culosis hospital not excelled by that 
of any city. Lack of sufficient bed 
space, however, still hampers the ef- 
forts of health officials to control the 
disease. First consideration necessar- 
ily must be given to those most desper- 
ately sick. They, of course, are the 
cases least likely to be cured, but for 
humane reasons they must be given 




TUBERCULOSIS HOSPITAL SINCE 1919 
18 



hospital care first of all. As a result 
many whose disease is less advanced, 
and might be quickly checked by 
prompt hospitalization, must remain 
on the waiting list with such care as 
can be given them in clinics and by 
field nurses. 

The need for more beds also makes 
it necessary at times to discharge con- 
valescents from the hospital, before 
they are really strong enough to go, 
in order to provide places for emer- 
gency cases that must have immediate 
hospital care. As a result many such 
discharged convalescents again break 
down with the disease and again be- 
come dependent upon the community. 

It is believed that the additional 
beds contemplated by the proposed 
bond issue for health purposes will 
remedy this situation and stop the 
great economic loss caused by the re- 
peated return for hospitalization of 
persons who under present conditions 
are required to leave the hospital 
before their disease is completely 
arrested. 



In the last twenty years throughout 
the United States hospitals for the 
tuberculous have greatly increased in 
number and size, and great improve- 
ments have been made in the type of 
care provided within the hospitals. 

In 1908 there were in California 
10 institutions for care of the tuber- 
culous and they provided a total of 
465 beds. Now, in 1928, there are 
more than 50 institutions in Califor- 
nia for tuberculosis cases and they 
provide more than 5500 beds. 

In 1904 when the first directory of 
tuberculosis hospitals in the United 
States was published there were about 
100 institutions for care of the tuber- 
culous and they provided fewer than 
8000 beds. In 1928 the number of 
institutions for the tuberculous in the 
United States had increased to more 
than 600 and the number of beds to 
more than 72,000. 

As more and better hospital care 
has been provided for persons with 
tuberculosis there has been a marked 
decrease in the number of deaths from 
the disease. 




THE BEGINNING OF THE HEALTH FARM 



19 



Tuberculosis Death Rate Now Reduced 
To Lowest Point on Record 



ITT is probable that no city ever ex- 
^ perienced a quicker reduction in its 
tuberculosis death rate than the drop 
in San Francisco's rate immediately 
after the great fire of 1906. The 
fire carried on a four-day campaign 
against tuberculosis that was effective, 
but it cost more than $500,000,000. 
Breeding places of the disease were 
wiped out by the thousand. Outdoor 
life was suddenly forced upon thou- 
sands of persons who customarily slept 
with locked windows and believed 
that night air was poisonous. 

The accompanying chart illustrates 
the number of deaths from tubercu- 
losis in San Francisco each year since 
1900. Note the great drop in the 
number of deaths that immediately 
followed the fire of April, 1906. This 
reduction was only in part caused by 
the fact that many persons moved 
from the city temporarily after the 
fire. The city quickly recovered its 
former number of inhabitants, and 
more, but tuberculosis never regained 
the ground it had lost. For instance, 
in the census year 1910 San Francisco 
had about 75,000 more people than 
when the census of 1900 was taken, 
but about 250 fewer deaths from 
tuberculosis. 

For years before the great fire 
tuberculosis killed with monotonous 
regularity about 100 persons every 
month. Its annual toll was close to 
1200 persons. It has never since 
killed more than 960 in any one year. 
In 1927 it killed 593. This is the 
lowest annual mark on record. 

In comparing the total for 1927 
with the number killed each year be- 
fore the great fire it should be borne 
in mind also that the city is now twice 
as large as it was then. 

The population of San Francisco, 
as estimated by the Bureau of the 
Census, the number of deaths from 
tuberculosis and the death rate per 



100,000 of population for each year 
since 1900 follow: 



Year 


Population 


Deaths 


Rate 


1900 


342,782 


1132 


330 


1901 


350,913 


1161 


330 


1902 


358,420 


1142 


318 


1903 


365,927 


1208 


330 


1904 


373,434 


1151 


308 


1905 


380,941 


1175 


308 


1906 


388,448 


813 


209 


1907 


395,955 


818 


206 


1908 


403,462 


856 


212 


1909 


410,969 


837 


203 


1910 


418,838 


886 


211 


1911 


428,084 


809 


189 


1912 


437,330 


860 


196 


1913 


446,576 


884 


198 


1914 


455,822 


959 


210 


1915 


465,068 


962 


206 


1916 


474,314 


897 


189 


1917 


483,560 


854 


176 


1918 


492,806 


943 


191 


1919 


502,052 


922 


183 


1920 


511,298 


682 


133 


1921 


520,544 


648 


124 


1922 


529,790 


648 


122 


1923 


539,036 


680 


126 


1924 


548,282 


659 


120 


1925 


557,518 


644 


115 


1926 


566,774 


611 


107 


1927 


576,020 


593 


102 



It is contended by many persons 
that the census estimates of popula- 
tion for recent years are far less than 
the actual population of San Fran- 
cisco. If that is true the reduction in 
the death rate in recent years has been 
even greater than shown by the fig- 
ures in this table. For instance, if the 
rate is computed from the chamber 
of commerce estimate of population 
instead of the census estimate, San 
Francisco's tuberculosis death rate in 
1927 was 80 per 100,000 of popula- 
tion instead of 102. 

Whether the fire of 1906 was en- 
tirely responsible for the great reduc- 
tion in tuberculosis in San Francisco 
that immediately followed cannot be 
said with certainty. The fact should 
not be overlooked that in 1906, as 
noted elsewhere in this booklet, the 
open-air treatment of the tuberculous 
at the county hospital and their segre- 
gation to prevent the spread of infec- 



20 



tion among other patients first began. 

At about this time also impetus was 
given to various activities calculated 
to lessen disease, such as the opening 
of free clinics, the employment of field 
nurses, medical inspection of school 
children, municipal inspection and 
regulation of milk and meat supplies 
and a widespread campaign of public 
education about health. An interna- 
tional congress on tuberculosis was 
held in Washington, D. C, in 1908, 
and this did much to increase public 
interest in the war against disease. 

Another important influence was the 
rapid increase in the number of public 
and private hospitals for the treatment 
of persons with tuberculosis. 

Another great decrease in the tu- 
berlosis death rate took place about 
1-920 throughout the United States as 
well as in San Francisco. Some per- 
sons say the epidemic of influenza that 
swept the country in 1918 and 1919 
was principally responsible for this 
drop, believing that influenza killed 
many persons in 1918 and 1919 who 
would othenvise have died of tuber- 
culosis within the next few years. 



Others attribute the great decrease 
in the tuberculosis death rate that has 
taken place in the last eight years to 
the unusual prosperity of those years. 
Greater numbers of people get better 
wages, live in better homes and have 
better food. There are fewer desper- 
ately poor people. Hours of labor are 
less than they used to be. People have 
more time for rest and recreation. 
Cheap transportation makes it possible 
for more people to get out into the 
sunshine and fresh air, and to get out 
often. The number of persons that 
take part in outdoor sports has tre- 
mendously increased. 

Various influences, some exerted by 
natural laws and other directed by 
man, have contributed to the long- 
continued decline of tuberculosis. 
There is no way to measure separately 
how much each of many influences has 
accomplished. 

In California in the last twenty 
years many changes for the better have 
come about through legislation that 
has improved conditions under which 
the great mass of people work and 
live. All this has a bearing on the 
reduction of tuberculosis. 



1200 

1120 
1040 
960 
880 
600 
720 
640 
560 
460 
400 
320 
240 
160 
80 
O 



TUBERCULOSIS DEATHS IN SANTRANCISCO 
EACH YEAR SINCE 1900 



1200 
1120 
1040 

960 
880 
800 
720 
640 
560 
4 80 
400 
320 
240 
160 
60 

o 



1900 01 01 03 04 OS 06 07 08 09 



19 10 li 31 13 24 2$ 16 17 



21 



The improvement that has taken 
place with respect to tuberculosis in 
San Francisco is characteristic of the 
change that has taken place through- 
out the United States, although there 
has been a far greater decline in the 
death rate of San Francisco than in 
the death rate of the United States as 
a whole. 

The chart on this page shows how 
the rate has declined in San Francisco 
and how it has declined in the whole 
United States since 1900. The chart 
is based upon statistics published by 
the United States Bureau of the Cen- 
sus. For the United States as a whole 
there was a slight increase in 1926 
over 1925. There was a reduction 
again in 1927, but the exact figure for 
the year has not yet been published by 
the census bureau. 

The decline in San Francisco from 



1905 to 1906 was probably not in fact 
so extreme as indicated by the chart, 
for in calculating rates the census bu- 
reau made no allowance for the tem- 
porary decrease in San Francisco's 
population immediately following the 
earthquake and fire of 1906. 

It is interesting to note how much 
greater San Francisco's rate was than 
the rate for the United States as a 
whole from 1900 to 1905 and how 
the rate for San Francisco is now 
little above that of the rate for the 
whole United States. 

As explained previously in this 
booklet many persons believe the cen- 
sus bureau greatly underestimates San 
Francisco's population. If local esti- 
mates of population are correct, San 
Francisco's tuberculosis death rate is 
now less than the rate for the United 
States as a whole. 



1900 01 
340 


OX 03 04 05 06 07 08 09 igio II 12 13 14 15 16 17 18 19 1920 21 


22 


23 


Z4 


25 


26 


27 
340 


320 














320 


300 














300 


280 


\ How tuberculosis death rate 
\ has declined since 1Q00 












280 


266 
240 


\ san Francisco 

\ ---— . United States 












260 
240 


220 














220 


200 ...... 

180 
160 
140 














200 

ieo 

160 
140 


120 


**.. 












120 


IOO 
80 


*•— 


—. 


*"••-. 


-.. 








*— MOO 
80 


eo 














60 


40 














40 


20 














20 


o 

1900 01 


02. 03 04 o5 06 07 08 09 1910 II 12 13 14 15 16 17 18 19 1920 21 


22 


I J 


24- 


25 


26 


27° 



22 



< «"|pUBLIC health is purchasable. Within natural 
limitations a community can determine its own 
death rate." — Biggs. 



"HpHREE-FOURTHS of the deaths from tuber- 
culosis would be avoided if knowledge now 
existing among well-informed men were applied 
to a reasonable extent." — From the report of the 
National Conservation Commission. 



Press of 

The Margaret marv morgan Co. 
s. F.